|
LACTULOSE 20 GRAM/30 ML ORAL SOLUTION
|
Facility
|
IP
|
$2.59
|
|
|
Service Code
|
NDC 50383077933
|
| Hospital Charge Code |
150919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$2.59 |
| Rate for Payer: Aetna Commercial |
$2.33
|
| Rate for Payer: ASR ASR |
$2.51
|
| Rate for Payer: ASR Commercial |
$2.51
|
| Rate for Payer: BCBS Trust/PPO |
$2.11
|
| Rate for Payer: BCN Commercial |
$2.01
|
| Rate for Payer: Cash Price |
$2.07
|
| Rate for Payer: Cofinity Commercial |
$2.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.07
|
| Rate for Payer: Healthscope Commercial |
$2.59
|
| Rate for Payer: Healthscope Whirlpool |
$2.51
|
| Rate for Payer: Mclaren Commercial |
$2.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.20
|
| Rate for Payer: Nomi Health Commercial |
$2.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.28
|
|
|
LACTULOSE 20 GRAM/30 ML ORAL SOLUTION
|
Facility
|
IP
|
$4.61
|
|
|
Service Code
|
NDC 50383077930
|
| Hospital Charge Code |
150919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$4.61 |
| Rate for Payer: Aetna Commercial |
$4.15
|
| Rate for Payer: ASR ASR |
$4.47
|
| Rate for Payer: ASR Commercial |
$4.47
|
| Rate for Payer: BCBS Trust/PPO |
$3.76
|
| Rate for Payer: BCN Commercial |
$3.57
|
| Rate for Payer: Cash Price |
$3.69
|
| Rate for Payer: Cofinity Commercial |
$4.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.69
|
| Rate for Payer: Healthscope Commercial |
$4.61
|
| Rate for Payer: Healthscope Whirlpool |
$4.47
|
| Rate for Payer: Mclaren Commercial |
$4.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.92
|
| Rate for Payer: Nomi Health Commercial |
$3.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.06
|
|
|
LACTULOSE 20 GRAM/30 ML ORAL SOLUTION
|
Facility
|
OP
|
$4.61
|
|
|
Service Code
|
NDC 50383077930
|
| Hospital Charge Code |
150919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.84 |
| Max. Negotiated Rate |
$4.61 |
| Rate for Payer: Aetna Commercial |
$4.15
|
| Rate for Payer: Aetna Medicare |
$2.30
|
| Rate for Payer: ASR ASR |
$4.47
|
| Rate for Payer: ASR Commercial |
$4.47
|
| Rate for Payer: BCBS Complete |
$1.84
|
| Rate for Payer: BCBS Trust/PPO |
$3.78
|
| Rate for Payer: BCN Commercial |
$3.57
|
| Rate for Payer: Cash Price |
$3.69
|
| Rate for Payer: Cofinity Commercial |
$4.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.69
|
| Rate for Payer: Healthscope Commercial |
$4.61
|
| Rate for Payer: Healthscope Whirlpool |
$4.47
|
| Rate for Payer: Mclaren Commercial |
$4.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.92
|
| Rate for Payer: Nomi Health Commercial |
$3.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.04
|
| Rate for Payer: Priority Health Narrow Network |
$3.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.06
|
|
|
LACTULOSE 20 GRAM/30 ML ORAL SOLUTION
|
Facility
|
IP
|
$6.62
|
|
|
Service Code
|
NDC 00121115400
|
| Hospital Charge Code |
150919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.30 |
| Max. Negotiated Rate |
$6.62 |
| Rate for Payer: Aetna Commercial |
$5.96
|
| Rate for Payer: ASR ASR |
$6.42
|
| Rate for Payer: ASR Commercial |
$6.42
|
| Rate for Payer: BCBS Trust/PPO |
$5.39
|
| Rate for Payer: BCN Commercial |
$5.13
|
| Rate for Payer: Cash Price |
$5.30
|
| Rate for Payer: Cofinity Commercial |
$6.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.30
|
| Rate for Payer: Healthscope Commercial |
$6.62
|
| Rate for Payer: Healthscope Whirlpool |
$6.42
|
| Rate for Payer: Mclaren Commercial |
$5.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.63
|
| Rate for Payer: Nomi Health Commercial |
$5.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5.83
|
|
|
LACTULOSE 20 GRAM/30 ML ORAL SOLUTION
|
Facility
|
IP
|
$6.05
|
|
|
Service Code
|
NDC 00116400511
|
| Hospital Charge Code |
150919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.93 |
| Max. Negotiated Rate |
$6.05 |
| Rate for Payer: Aetna Commercial |
$5.44
|
| Rate for Payer: ASR ASR |
$5.87
|
| Rate for Payer: ASR Commercial |
$5.87
|
| Rate for Payer: BCBS Trust/PPO |
$4.93
|
| Rate for Payer: BCN Commercial |
$4.69
|
| Rate for Payer: Cash Price |
$4.84
|
| Rate for Payer: Cofinity Commercial |
$5.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.84
|
| Rate for Payer: Healthscope Commercial |
$6.05
|
| Rate for Payer: Healthscope Whirlpool |
$5.87
|
| Rate for Payer: Mclaren Commercial |
$5.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.14
|
| Rate for Payer: Nomi Health Commercial |
$4.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5.32
|
|
|
LACTULOSE 20 GRAM/30 ML ORAL SOLUTION
|
Facility
|
OP
|
$6.62
|
|
|
Service Code
|
NDC 00121115430
|
| Hospital Charge Code |
150919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.65 |
| Max. Negotiated Rate |
$6.62 |
| Rate for Payer: Aetna Commercial |
$5.96
|
| Rate for Payer: Aetna Medicare |
$3.31
|
| Rate for Payer: ASR ASR |
$6.42
|
| Rate for Payer: ASR Commercial |
$6.42
|
| Rate for Payer: BCBS Complete |
$2.65
|
| Rate for Payer: BCBS Trust/PPO |
$5.42
|
| Rate for Payer: BCN Commercial |
$5.13
|
| Rate for Payer: Cash Price |
$5.30
|
| Rate for Payer: Cofinity Commercial |
$6.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.30
|
| Rate for Payer: Healthscope Commercial |
$6.62
|
| Rate for Payer: Healthscope Whirlpool |
$6.42
|
| Rate for Payer: Mclaren Commercial |
$5.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.63
|
| Rate for Payer: Nomi Health Commercial |
$5.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5.80
|
| Rate for Payer: Priority Health Narrow Network |
$4.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5.83
|
|
|
LACTULOSE 20 GRAM/30 ML ORAL SOLUTION
|
Facility
|
IP
|
$6.05
|
|
|
Service Code
|
NDC 00116400530
|
| Hospital Charge Code |
150919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.93 |
| Max. Negotiated Rate |
$6.05 |
| Rate for Payer: Aetna Commercial |
$5.44
|
| Rate for Payer: ASR ASR |
$5.87
|
| Rate for Payer: ASR Commercial |
$5.87
|
| Rate for Payer: BCBS Trust/PPO |
$4.93
|
| Rate for Payer: BCN Commercial |
$4.69
|
| Rate for Payer: Cash Price |
$4.84
|
| Rate for Payer: Cofinity Commercial |
$5.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.84
|
| Rate for Payer: Healthscope Commercial |
$6.05
|
| Rate for Payer: Healthscope Whirlpool |
$5.87
|
| Rate for Payer: Mclaren Commercial |
$5.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.14
|
| Rate for Payer: Nomi Health Commercial |
$4.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5.32
|
|
|
LAMOTRIGINE 200 MG TABLET
|
Facility
|
IP
|
$183.30
|
|
|
Service Code
|
NDC 51672413304
|
| Hospital Charge Code |
13983
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.14 |
| Max. Negotiated Rate |
$183.30 |
| Rate for Payer: Aetna Commercial |
$164.97
|
| Rate for Payer: ASR ASR |
$177.80
|
| Rate for Payer: ASR Commercial |
$177.80
|
| Rate for Payer: BCBS Trust/PPO |
$149.37
|
| Rate for Payer: BCN Commercial |
$142.11
|
| Rate for Payer: Cash Price |
$146.64
|
| Rate for Payer: Cofinity Commercial |
$172.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$146.64
|
| Rate for Payer: Healthscope Commercial |
$183.30
|
| Rate for Payer: Healthscope Whirlpool |
$177.80
|
| Rate for Payer: Mclaren Commercial |
$164.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$155.80
|
| Rate for Payer: Nomi Health Commercial |
$150.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$119.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$161.30
|
|
|
LAMOTRIGINE 200 MG TABLET
|
Facility
|
OP
|
$183.30
|
|
|
Service Code
|
NDC 51672413304
|
| Hospital Charge Code |
13983
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.32 |
| Max. Negotiated Rate |
$183.30 |
| Rate for Payer: Aetna Commercial |
$164.97
|
| Rate for Payer: Aetna Medicare |
$91.65
|
| Rate for Payer: ASR ASR |
$177.80
|
| Rate for Payer: ASR Commercial |
$177.80
|
| Rate for Payer: BCBS Complete |
$73.32
|
| Rate for Payer: BCBS Trust/PPO |
$150.10
|
| Rate for Payer: BCN Commercial |
$142.11
|
| Rate for Payer: Cash Price |
$146.64
|
| Rate for Payer: Cofinity Commercial |
$172.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$146.64
|
| Rate for Payer: Healthscope Commercial |
$183.30
|
| Rate for Payer: Healthscope Whirlpool |
$177.80
|
| Rate for Payer: Mclaren Commercial |
$164.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$155.80
|
| Rate for Payer: Nomi Health Commercial |
$150.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$119.14
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$160.61
|
| Rate for Payer: Priority Health Narrow Network |
$128.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$161.30
|
|
|
LAMOTRIGINE 200 MG TABLET
|
Facility
|
IP
|
$88.83
|
|
|
Service Code
|
NDC 65862023060
|
| Hospital Charge Code |
13983
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.74 |
| Max. Negotiated Rate |
$88.83 |
| Rate for Payer: Aetna Commercial |
$79.95
|
| Rate for Payer: ASR ASR |
$86.17
|
| Rate for Payer: ASR Commercial |
$86.17
|
| Rate for Payer: BCBS Trust/PPO |
$72.39
|
| Rate for Payer: BCN Commercial |
$68.87
|
| Rate for Payer: Cash Price |
$71.06
|
| Rate for Payer: Cofinity Commercial |
$83.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.06
|
| Rate for Payer: Healthscope Commercial |
$88.83
|
| Rate for Payer: Healthscope Whirlpool |
$86.17
|
| Rate for Payer: Mclaren Commercial |
$79.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.51
|
| Rate for Payer: Nomi Health Commercial |
$72.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$78.17
|
|
|
LAMOTRIGINE 200 MG TABLET
|
Facility
|
OP
|
$88.83
|
|
|
Service Code
|
NDC 65862023060
|
| Hospital Charge Code |
13983
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.53 |
| Max. Negotiated Rate |
$88.83 |
| Rate for Payer: Aetna Commercial |
$79.95
|
| Rate for Payer: Aetna Medicare |
$44.42
|
| Rate for Payer: ASR ASR |
$86.17
|
| Rate for Payer: ASR Commercial |
$86.17
|
| Rate for Payer: BCBS Complete |
$35.53
|
| Rate for Payer: BCBS Trust/PPO |
$72.74
|
| Rate for Payer: BCN Commercial |
$68.87
|
| Rate for Payer: Cash Price |
$71.06
|
| Rate for Payer: Cofinity Commercial |
$83.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.06
|
| Rate for Payer: Healthscope Commercial |
$88.83
|
| Rate for Payer: Healthscope Whirlpool |
$86.17
|
| Rate for Payer: Mclaren Commercial |
$79.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.51
|
| Rate for Payer: Nomi Health Commercial |
$72.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.74
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$77.83
|
| Rate for Payer: Priority Health Narrow Network |
$62.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$78.17
|
|
|
LAMOTRIGINE 25 MG TABLET
|
Facility
|
IP
|
$321.95
|
|
|
Service Code
|
NDC 00904700761
|
| Hospital Charge Code |
13981
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$209.27 |
| Max. Negotiated Rate |
$321.95 |
| Rate for Payer: Aetna Commercial |
$289.76
|
| Rate for Payer: ASR ASR |
$312.29
|
| Rate for Payer: ASR Commercial |
$312.29
|
| Rate for Payer: BCBS Trust/PPO |
$262.36
|
| Rate for Payer: BCN Commercial |
$249.61
|
| Rate for Payer: Cash Price |
$257.56
|
| Rate for Payer: Cofinity Commercial |
$302.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.56
|
| Rate for Payer: Healthscope Commercial |
$321.95
|
| Rate for Payer: Healthscope Whirlpool |
$312.29
|
| Rate for Payer: Mclaren Commercial |
$289.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$273.66
|
| Rate for Payer: Nomi Health Commercial |
$264.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$209.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$283.32
|
|
|
LAMOTRIGINE 25 MG TABLET
|
Facility
|
OP
|
$321.95
|
|
|
Service Code
|
NDC 00904700761
|
| Hospital Charge Code |
13981
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$128.78 |
| Max. Negotiated Rate |
$321.95 |
| Rate for Payer: Aetna Commercial |
$289.76
|
| Rate for Payer: Aetna Medicare |
$160.98
|
| Rate for Payer: ASR ASR |
$312.29
|
| Rate for Payer: ASR Commercial |
$312.29
|
| Rate for Payer: BCBS Complete |
$128.78
|
| Rate for Payer: BCBS Trust/PPO |
$263.64
|
| Rate for Payer: BCN Commercial |
$249.61
|
| Rate for Payer: Cash Price |
$257.56
|
| Rate for Payer: Cofinity Commercial |
$302.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.56
|
| Rate for Payer: Healthscope Commercial |
$321.95
|
| Rate for Payer: Healthscope Whirlpool |
$312.29
|
| Rate for Payer: Mclaren Commercial |
$289.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$273.66
|
| Rate for Payer: Nomi Health Commercial |
$264.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$209.27
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$282.09
|
| Rate for Payer: Priority Health Narrow Network |
$225.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$283.32
|
|
|
LARYNGOSCOPY, DIRECT, OPERATIVE, WITH FOREIGN BODY REMOVAL;
|
Facility
|
OP
|
$2,618.88
|
|
|
Service Code
|
CPT 31530
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$905.63 |
| Max. Negotiated Rate |
$2,618.88 |
| Rate for Payer: Aetna Medicare |
$1,689.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,112.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,112.00
|
| Rate for Payer: BCBS Complete |
$950.91
|
| Rate for Payer: BCBS MAPPO |
$1,689.60
|
| Rate for Payer: BCN Medicare Advantage |
$1,689.60
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,689.60
|
| Rate for Payer: Humana Choice PPO Medicare |
$1,689.60
|
| Rate for Payer: Mclaren Medicaid |
$905.63
|
| Rate for Payer: Mclaren Medicare |
$1,689.60
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,774.08
|
| Rate for Payer: Meridian Medicaid |
$950.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,943.04
|
| Rate for Payer: PACE Medicare |
$1,605.12
|
| Rate for Payer: PACE SWMI |
$1,689.60
|
| Rate for Payer: PHP Commercial |
$1,858.56
|
| Rate for Payer: PHP Medicaid |
$905.63
|
| Rate for Payer: PHP Medicare Advantage |
$1,689.60
|
| Rate for Payer: Priority Health Choice Medicaid |
$905.63
|
| Rate for Payer: Priority Health Medicare |
$1,689.60
|
| Rate for Payer: Railroad Medicare Medicare |
$1,689.60
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,689.60
|
| Rate for Payer: UHC Exchange |
$2,618.88
|
| Rate for Payer: UHC Medicare Advantage |
$1,689.60
|
| Rate for Payer: UHCCP DNSP |
$1,689.60
|
| Rate for Payer: UHCCP Medicaid |
$905.63
|
| Rate for Payer: VA VA |
$1,689.60
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
OP
|
$50.75
|
|
|
Service Code
|
NDC 17478062512
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$50.75 |
| Rate for Payer: Aetna Commercial |
$45.68
|
| Rate for Payer: Aetna Medicare |
$25.38
|
| Rate for Payer: ASR ASR |
$49.23
|
| Rate for Payer: ASR Commercial |
$49.23
|
| Rate for Payer: BCBS Complete |
$20.30
|
| Rate for Payer: BCBS Trust/PPO |
$41.56
|
| Rate for Payer: BCN Commercial |
$39.35
|
| Rate for Payer: Cash Price |
$40.60
|
| Rate for Payer: Cofinity Commercial |
$47.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.60
|
| Rate for Payer: Healthscope Commercial |
$50.75
|
| Rate for Payer: Healthscope Whirlpool |
$49.23
|
| Rate for Payer: Mclaren Commercial |
$45.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.14
|
| Rate for Payer: Nomi Health Commercial |
$41.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.99
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$44.47
|
| Rate for Payer: Priority Health Narrow Network |
$35.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$44.66
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
OP
|
$46.38
|
|
|
Service Code
|
NDC 61314054703
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.55 |
| Max. Negotiated Rate |
$46.38 |
| Rate for Payer: Aetna Commercial |
$41.74
|
| Rate for Payer: Aetna Medicare |
$23.19
|
| Rate for Payer: ASR ASR |
$44.99
|
| Rate for Payer: ASR Commercial |
$44.99
|
| Rate for Payer: BCBS Complete |
$18.55
|
| Rate for Payer: BCBS Trust/PPO |
$37.98
|
| Rate for Payer: BCN Commercial |
$35.96
|
| Rate for Payer: Cash Price |
$37.11
|
| Rate for Payer: Cofinity Commercial |
$43.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.10
|
| Rate for Payer: Healthscope Commercial |
$46.38
|
| Rate for Payer: Healthscope Whirlpool |
$44.99
|
| Rate for Payer: Mclaren Commercial |
$41.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.42
|
| Rate for Payer: Nomi Health Commercial |
$38.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.15
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$40.64
|
| Rate for Payer: Priority Health Narrow Network |
$32.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$40.81
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
IP
|
$50.75
|
|
|
Service Code
|
NDC 17478062512
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.99 |
| Max. Negotiated Rate |
$50.75 |
| Rate for Payer: Aetna Commercial |
$45.68
|
| Rate for Payer: ASR ASR |
$49.23
|
| Rate for Payer: ASR Commercial |
$49.23
|
| Rate for Payer: BCBS Trust/PPO |
$41.36
|
| Rate for Payer: BCN Commercial |
$39.35
|
| Rate for Payer: Cash Price |
$40.60
|
| Rate for Payer: Cofinity Commercial |
$47.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.60
|
| Rate for Payer: Healthscope Commercial |
$50.75
|
| Rate for Payer: Healthscope Whirlpool |
$49.23
|
| Rate for Payer: Mclaren Commercial |
$45.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.14
|
| Rate for Payer: Nomi Health Commercial |
$41.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$44.66
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
IP
|
$26.46
|
|
|
Service Code
|
NDC 61314054701
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.20 |
| Max. Negotiated Rate |
$26.46 |
| Rate for Payer: Aetna Commercial |
$23.81
|
| Rate for Payer: ASR ASR |
$25.67
|
| Rate for Payer: ASR Commercial |
$25.67
|
| Rate for Payer: BCBS Trust/PPO |
$21.56
|
| Rate for Payer: BCN Commercial |
$20.51
|
| Rate for Payer: Cash Price |
$21.17
|
| Rate for Payer: Cofinity Commercial |
$24.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.17
|
| Rate for Payer: Healthscope Commercial |
$26.46
|
| Rate for Payer: Healthscope Whirlpool |
$25.67
|
| Rate for Payer: Mclaren Commercial |
$23.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.49
|
| Rate for Payer: Nomi Health Commercial |
$21.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.28
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
OP
|
$19.22
|
|
|
Service Code
|
NDC 70069042101
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.69 |
| Max. Negotiated Rate |
$19.22 |
| Rate for Payer: Aetna Commercial |
$17.30
|
| Rate for Payer: Aetna Medicare |
$9.61
|
| Rate for Payer: ASR ASR |
$18.64
|
| Rate for Payer: ASR Commercial |
$18.64
|
| Rate for Payer: BCBS Complete |
$7.69
|
| Rate for Payer: BCBS Trust/PPO |
$15.74
|
| Rate for Payer: BCN Commercial |
$14.90
|
| Rate for Payer: Cash Price |
$15.37
|
| Rate for Payer: Cofinity Commercial |
$18.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.38
|
| Rate for Payer: Healthscope Commercial |
$19.22
|
| Rate for Payer: Healthscope Whirlpool |
$18.64
|
| Rate for Payer: Mclaren Commercial |
$17.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.34
|
| Rate for Payer: Nomi Health Commercial |
$15.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.49
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16.84
|
| Rate for Payer: Priority Health Narrow Network |
$13.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.91
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
OP
|
$26.46
|
|
|
Service Code
|
NDC 61314054701
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.58 |
| Max. Negotiated Rate |
$26.46 |
| Rate for Payer: Aetna Commercial |
$23.81
|
| Rate for Payer: Aetna Medicare |
$13.23
|
| Rate for Payer: ASR ASR |
$25.67
|
| Rate for Payer: ASR Commercial |
$25.67
|
| Rate for Payer: BCBS Complete |
$10.58
|
| Rate for Payer: BCBS Trust/PPO |
$21.67
|
| Rate for Payer: BCN Commercial |
$20.51
|
| Rate for Payer: Cash Price |
$21.17
|
| Rate for Payer: Cofinity Commercial |
$24.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.17
|
| Rate for Payer: Healthscope Commercial |
$26.46
|
| Rate for Payer: Healthscope Whirlpool |
$25.67
|
| Rate for Payer: Mclaren Commercial |
$23.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.49
|
| Rate for Payer: Nomi Health Commercial |
$21.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$23.18
|
| Rate for Payer: Priority Health Narrow Network |
$18.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.28
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
IP
|
$19.22
|
|
|
Service Code
|
NDC 70069042101
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.49 |
| Max. Negotiated Rate |
$19.22 |
| Rate for Payer: Aetna Commercial |
$17.30
|
| Rate for Payer: ASR ASR |
$18.64
|
| Rate for Payer: ASR Commercial |
$18.64
|
| Rate for Payer: BCBS Trust/PPO |
$15.66
|
| Rate for Payer: BCN Commercial |
$14.90
|
| Rate for Payer: Cash Price |
$15.37
|
| Rate for Payer: Cofinity Commercial |
$18.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.38
|
| Rate for Payer: Healthscope Commercial |
$19.22
|
| Rate for Payer: Healthscope Whirlpool |
$18.64
|
| Rate for Payer: Mclaren Commercial |
$17.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.34
|
| Rate for Payer: Nomi Health Commercial |
$15.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.91
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
IP
|
$50.75
|
|
|
Service Code
|
NDC 00517083001
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.99 |
| Max. Negotiated Rate |
$50.75 |
| Rate for Payer: Aetna Commercial |
$45.68
|
| Rate for Payer: ASR ASR |
$49.23
|
| Rate for Payer: ASR Commercial |
$49.23
|
| Rate for Payer: BCBS Trust/PPO |
$41.36
|
| Rate for Payer: BCN Commercial |
$39.35
|
| Rate for Payer: Cash Price |
$40.60
|
| Rate for Payer: Cofinity Commercial |
$47.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.60
|
| Rate for Payer: Healthscope Commercial |
$50.75
|
| Rate for Payer: Healthscope Whirlpool |
$49.23
|
| Rate for Payer: Mclaren Commercial |
$45.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.14
|
| Rate for Payer: Nomi Health Commercial |
$41.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$44.66
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
OP
|
$50.75
|
|
|
Service Code
|
NDC 00517083001
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$50.75 |
| Rate for Payer: Aetna Commercial |
$45.68
|
| Rate for Payer: Aetna Medicare |
$25.38
|
| Rate for Payer: ASR ASR |
$49.23
|
| Rate for Payer: ASR Commercial |
$49.23
|
| Rate for Payer: BCBS Complete |
$20.30
|
| Rate for Payer: BCBS Trust/PPO |
$41.56
|
| Rate for Payer: BCN Commercial |
$39.35
|
| Rate for Payer: Cash Price |
$40.60
|
| Rate for Payer: Cofinity Commercial |
$47.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.60
|
| Rate for Payer: Healthscope Commercial |
$50.75
|
| Rate for Payer: Healthscope Whirlpool |
$49.23
|
| Rate for Payer: Mclaren Commercial |
$45.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.14
|
| Rate for Payer: Nomi Health Commercial |
$41.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.99
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$44.47
|
| Rate for Payer: Priority Health Narrow Network |
$35.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$44.66
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
IP
|
$46.38
|
|
|
Service Code
|
NDC 61314054703
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.15 |
| Max. Negotiated Rate |
$46.38 |
| Rate for Payer: Aetna Commercial |
$41.74
|
| Rate for Payer: ASR ASR |
$44.99
|
| Rate for Payer: ASR Commercial |
$44.99
|
| Rate for Payer: BCBS Trust/PPO |
$37.80
|
| Rate for Payer: BCN Commercial |
$35.96
|
| Rate for Payer: Cash Price |
$37.11
|
| Rate for Payer: Cofinity Commercial |
$43.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.10
|
| Rate for Payer: Healthscope Commercial |
$46.38
|
| Rate for Payer: Healthscope Whirlpool |
$44.99
|
| Rate for Payer: Mclaren Commercial |
$41.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.42
|
| Rate for Payer: Nomi Health Commercial |
$38.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$40.81
|
|
|
LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT
|
Facility
|
OP
|
$19,492.67
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
21044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$893.39 |
| Max. Negotiated Rate |
$19,492.67 |
| Rate for Payer: Aetna Commercial |
$17,543.40
|
| Rate for Payer: Aetna Medicare |
$1,666.78
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,083.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,083.48
|
| Rate for Payer: ASR ASR |
$18,907.89
|
| Rate for Payer: ASR Commercial |
$18,907.89
|
| Rate for Payer: BCBS Complete |
$938.06
|
| Rate for Payer: BCBS MAPPO |
$1,666.78
|
| Rate for Payer: BCBS Trust/PPO |
$15,962.55
|
| Rate for Payer: BCN Commercial |
$15,112.67
|
| Rate for Payer: BCN Medicare Advantage |
$1,666.78
|
| Rate for Payer: Cash Price |
$15,594.14
|
| Rate for Payer: Cash Price |
$15,594.14
|
| Rate for Payer: Cofinity Commercial |
$18,323.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,594.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,666.78
|
| Rate for Payer: Healthscope Commercial |
$19,492.67
|
| Rate for Payer: Healthscope Whirlpool |
$18,907.89
|
| Rate for Payer: Humana Choice PPO Medicare |
$1,666.78
|
| Rate for Payer: Mclaren Commercial |
$17,543.40
|
| Rate for Payer: Mclaren Medicaid |
$893.39
|
| Rate for Payer: Mclaren Medicare |
$1,666.78
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,750.12
|
| Rate for Payer: Meridian Medicaid |
$938.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,916.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,568.77
|
| Rate for Payer: Nomi Health Commercial |
$15,983.99
|
| Rate for Payer: PACE Medicare |
$1,583.44
|
| Rate for Payer: PACE SWMI |
$1,666.78
|
| Rate for Payer: PHP Commercial |
$1,833.46
|
| Rate for Payer: PHP Medicaid |
$893.39
|
| Rate for Payer: PHP Medicare Advantage |
$1,666.78
|
| Rate for Payer: Priority Health Choice Medicaid |
$893.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,670.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,733.33
|
| Rate for Payer: Priority Health Medicare |
$1,666.78
|
| Rate for Payer: Priority Health Narrow Network |
$1,386.66
|
| Rate for Payer: Railroad Medicare Medicare |
$1,666.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17,153.55
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,666.78
|
| Rate for Payer: UHC Exchange |
$2,583.51
|
| Rate for Payer: UHC Medicare Advantage |
$1,666.78
|
| Rate for Payer: UHCCP DNSP |
$1,666.78
|
| Rate for Payer: UHCCP Medicaid |
$893.39
|
| Rate for Payer: VA VA |
$1,666.78
|
|
